How to manage dizziness due to heavy menstrual bleeding?

Management of Dizziness Due to Heavy Menstrual Bleeding

For dizziness caused by heavy menstrual bleeding, a levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment, reducing menstrual blood loss by 71-95% and addressing the underlying cause of lightheadedness. 1

Initial Assessment

• Evaluate severity of bleeding - bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation 1
• Test for pregnancy in all reproductive-age women with abnormal uterine bleeding 1
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss 1
• Consider complete blood count to assess for anemia as the cause of dizziness 2

First-Line Treatment Options

Hormonal Options:

• Levonorgestrel-releasing IUD (20 μg/day):

  • Most effective medical treatment, comparable to endometrial ablation 1
  • Reduces menstrual blood loss by 71-95% 1
  • Main effect is at the endometrial level with minimal systemic absorption 1
  • Provides contraception while treating heavy bleeding 1

• Cyclic oral progestin treatment:

  • Reduces bleeding by approximately 87% 1
  • May result in irregular bleeding patterns but often reduces menses to light bleeding 1
  • Consider for patients who cannot or prefer not to use an IUD 1

• High-dose oral or injectable progestin-only medications:

  • Consider for short-term use in hemodynamically unstable women with uncontrolled bleeding 1

Non-Hormonal Options:

• Tranexamic acid:
  • Reduces mean blood loss by 53.20 mL per cycle compared to placebo 3
  • Take only during days of bleeding 1
  • Caution: Contraindicated in patients with active intravascular clotting or history of thrombosis 4
  • May cause dizziness as a side effect 4

Second-Line Options

• NSAIDs (short-term treatment for 5-7 days):

  • Can reduce heavy menstrual bleeding 1
  • Less effective than tranexamic acid (73 mL less blood loss per cycle with tranexamic acid compared to NSAIDs) 3
  • Should be avoided in patients with history of spontaneous coronary artery dissection (SCAD) 1

• Combined hormonal contraceptives:

  • Effective for management of heavy menstrual bleeding 2
  • Consider in appropriate candidates without contraindications 5

Surgical Options (for refractory cases)

• Endometrial ablation techniques:

  • Consider when medical treatment fails 1
  • Thermal balloon, microwave, or radiofrequency methods 1
  • Low operative morbidity and can be performed as an outpatient procedure 2
  • More effective long-term than oral medical treatments 1

• Hysterectomy:

  • Definitive treatment when other options have failed 2
  • Consider only after less invasive procedures have been attempted 1

Management of Acute Dizziness

• Iron supplementation for iron-deficiency anemia 2
• In severe cases with significant anemia, consider blood transfusion 6
• Ensure adequate hydration and advise patient to change positions slowly 2

Special Considerations

• For adolescents with heavy menstrual bleeding and dizziness, consider bleeding disorder workup 7
• Patients on antiplatelet therapy may experience worsened menstrual bleeding; reassess the indication for ongoing antiplatelet therapy 1
• Avoid tranexamic acid in patients with history of thrombosis or at high risk for thromboembolism 4

Follow-up

• Monitor response to treatment and hemoglobin levels 2
• If bleeding persists and remains unacceptable despite treatment, consider alternative contraceptive methods or referral for surgical management 1